New Enquiry Form Your first and last name: Please leave this field empty. Your phone number: Your Email: Is this appointment for yourself?: —Please choose an option—YesNo What is the client's name?: What is your relationship to the client? What is the client's DOB?: Is the client over the age of 18?: —Please choose an option—YesNo If the client is over 18, you will need permission to be making an enquiry on their behalf. Do you have the clients permission to proceed with this enquiry?: —Please choose an option—YesNo What is your DOB: Client's pronouns: She/HerHe/HimThey/ThemOther Do you identify as any of the following? AboriginalTorres Strait IslanderAboriginal and Torres Strait Islander Would you prefer to see Brooke Skuse, our First Nations Psychologist? —Please choose an option—YesNo preference Please provide as much detail as possible about your reason for booking. ie: workplace conflict, anxiety or depression, cancer concerns, relationship breakdown. This does help to speed up the booking in process. : Preferred Days: MondayTuesdayWednesdayThursdayFridaySaturdayAny Day Preferred Times: Before WorkAfter WorkMorningLunchtimeAfternoonEveningAny Time Which service are you enquiring about?: Psychology Accredited Mental Health Social Worker Movement and Yoga Therapy Dietetics EMDR Clinical Hypnotherapy Exercise/Mental Health Physiotherapy Assessment and Testing NDIS Not Sure Yet Other Please note NDIS funding may only be used by those who have approved funds for such services and are either plan or self managed. —Please choose an option—Plan-ManagedSelf-Managed Is there a specific provider you would like to make appointments with at Lilley Place? —Please choose an option—YesNo Please name the provider/s: Do you have a preference for seeing either a Male or Female clinician? —Please choose an option—YesNo preference MaleFemale Which referral do you plan on using (if any) —Please choose an option—Mental Health Care Plan (MHCP)Chronic Disease Management Plan (CDM)Eating Disorder PlanHave an appointment to see GPNo GP referralUnsure (please discuss) Are you aware that sessions attract an out of pocket expense even with a Mental Health Care Plan in place? Please review our associated fees from our website. https://www.lilleyplace.com.au/services/#FeesRebates —Please choose an option—YesNo Would you like to use your private health fund to pay for the appointments?: —Please choose an option—YesNo How did you hear about us?:
